SCREENING FORM

THE SHELTER PROGRAM IS NOT AN IMMEDIATE EMERGENCY PROGRAM. AN APPLICATION PROCESS, BACKGROUND CHECK, AND INTERVIEW ARE REQUIRED BEFORE ACCEPTANCE INTO THE SHELTER PROGRAM.

IF YOU ARE HOMELESS AND IN NEED OF IMMEDIATE ASSISTANCE PLEASE 908-475-6218 DURING NORMAL BUSINESS HOURS OR CALL 211 AFTERHOURS AND ON WEEKENDS AND HOLIDAYS.

Screening for Service
(Please note - this is a screening and NOT an application for benefits.)
Are you a Social Service Referral Agency? If yes, which agency?
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Contact Information
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What services are you seeking from Family Promise of Warren County? Check all that apply.
Where do you currently live?
Are you currently facing eviction or foreclosure?
Have you received legal notice to appear in landlord/tenant court?
Have you contacted Legal Services of Northwest Jersey at 908-475-2010?

What is the dollar amount of your past due rent/mortgage? 

Reason for homelessness
What is your source(s) of income? Check all that apply.
Please provide the following information for any other adult household member seeking services.
(Full Name, Social Security Number, Full Address, Telephone, Email)
Do you have any children?
Please list the name and ages of the children
Are your school-aged children currently enrolled in school? 
Are YOU currently enrolled in school or vocational training?
List name(s) of school(s), school district, Day Care, Head Start, Early Head Start/CFRS
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Do you have a valid State of NJ driver's license?
Do you have a vehicle registered in your name?
What is your current legal marital status?

Do you or any adult member of your household have a criminal history or pending criminal charges?

Our emergency shelter is a low barrier program. That means having a criminal history does not prevent admission into the program however, failure to answer fully may result in discharge from the IHN Shelter Program.

Check all that apply. 

Are you or a member of your household currently receiving mental health services? If, yes please indicate which household member. (All information is confidential.)
Are you or a member of your household currently receiving treatment for alcohol or substance abuse. If, yes please indicate which household member. (All information is confidential.)
Do you have pets? *Note: FPWC IHN Shelter Program does not allow pets. However, we have contacts with animal welfare organizations and others that may be able to assist in animal shelter placement.
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Have you ever received emergency shelter placement from Family Promise of Warren County or a different Family Promise program?
How did you hear about Family Promise of Warren County?

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